1. Investigator Information the Leader at Each Participating Institution Is Considered

University of Texas MD Anderson Cancer Center Sister Institution Network Fund (SINF) Application

1. Investigator Information The leader at each participating institution is considered to be a Principal Investigator

Contact Institution Principal Investigator Title Department (Unit; email; telephone)

2. Biosketch Including Publications and Other Support (For each Principal Investigator attach an NIH Format Biosketch (Personal Statement optional) including publications and other support)

3. Check here if proposal is connected to a Moon Shots Program/Platform (cancermoonshots.org)

a. Please specify which Moon Shots Program/Platform ______

4. Application Title

(Enter title here)

5. Type of Application (Type ‘x’ into appropriate box, select one): New Application Revised Application

6. Application Category (Type ‘x’ into appropriate box, select one): Basic Laboratory Research Clinical, Translational, Population Educational Program

SINF Application Form (updated 9-2016) Page 1 of 6 Patient Oriented Research (clinical trials)

2 7. MD Anderson Principal Investigator Certification As Principal Investigator of this research proposal, I certify that the information provided is correct and complete to the best of my knowledge. If awarded financial support for this research proposal, I agree to:

1. Accept responsibility for the scientific and technical conduct of this research project, and, as required, provide a progress and final reports, in accordance with the instructions.

2. Acknowledge this grant as a source of support in publications.

The preferred citation is "Supported by a University of Texas MD Anderson Cancer Center Sister Institution Network Fund Research Grant."

Principal Investigator Name Signature Date

SINF Application Form (updated 9-2016) Page 3 of 8 Department Chair/Division Head Name Signature Date Abstract of Proposed Research (Limit to 300 words)

Enter abstract here – 300 words maximum.

4 8. (a)Budget of MD Anderson Component For dollar limit, please refer to Request for Application (RFA) announcement. Indicate whether request be allocated over one or two years.

Check whether request is for: 1 Year or 2 Years Role on Personnel Dollar Amount Requested (omit cents) Project Year 1 Year 2 Cal Mo Salary Fringe Salary Fringe Name Effort on Requested Benefits Requested BenefitsTotal PI Project

SUBTOT ALS

Year 1 Year 2 TOTAL Consultant Costs: NOT ELIGIBLE FOR SUPPORT Small Equipment (itemize)

Totals Supplies (itemize)

Totals General Travel, Patient Care, Alterations & Renovation: NOT ELIGIBLE Other Expenses (itemize) including SINF Application Form (updated 9-2016) Page 5 of 8 Travel of personnel listed above between institution s involved in this applicatio n.

Totals Consortium/ Contractual Costs: NOT ELIGIBLE FOR SUPPORT TOTAL DIRECT COSTS FOR PROJECT

6 8. (b) Budget Justification  A written justification is required for each personnel position, even if no salary is budgeted or received.  Itemized detailed justification is required for equipment items ≥ $1000 and any individual supply categories ≥ $2000, as well as any travel requested between collaborating institutions.  Computer equipment, temporary housing, tuition and other school costs require especially clear justification. Anything not included or justified in the original budget will need to be approved for payment at a later date.

Enter budget justifications here

SINF Application Form (updated 9-2016) Page 7 of 8 8. (c) Committed Budgets of Collaborating Institutions NOTE: This Section is for informational purposes only, and will be considered during review. The budget items listed here will NOT be considered for funding by the SINF, but rather represent the matching funds committed to the project by the Sister Institution or partner.

Laboratory Total Funds Personnel Funds Institution Principal Investigator Funds Committed / Committed Committed Number of Years